Are any of the following concerns that may keep you from reaching your goals?

Time

Motivation

Diet

Monetary Contraints

Health Concerns

Family/Friend Support

Other

Exercise History

Do you have any injuries or recent surgeries? If so, do you have a Dr.s permission to participate in an exercise program?

Are there any exercises that you are not able to do or do not feel right for your body?

Do you currently train?

If you train in a gym, please list the city and state of the gym.

How often do you exercise?

How long do you exercise (per session)?

How long have you been training? (cumulative)

What is a typical workout like for you?

(If not currently training) How long has it been since you stopped?

What type of exercise or activity were you involved in?

What did you like most about it?

What did you like least?

Focus Areas

What would you like to focus on?

Do you have cardio or strength training equipment to continue the program when not in a training session

Yes

No

Are you preparing for a contest or event?

Diet History

Diet priority

Diet priority

Muscle Gain

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Fat Loss

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Has your physician ever recommended a special diet for you? If yes, please describe.

Do you have any personal diet restrictions? (Vegan, etc.) If yes, please describe.

Have you ever followed a regimented diet in the past? If yes, please describe.

Do you have any food allergies? If yes, please describe.

Are you taking any supplements/vitamins/herbs? If yes, please describe.

Number

Thank you!

Please complete the form above and print the form below and bring to your next session.

Waiver and Release of Liability

I, _____________________________, intending to be legally bound, and recognizing the danger involved in physical exercise, do agree as follows:

In consideration for the services rendered by, The Chickfit Studio LLc, Linda Mitchell, Certified Personal Trainer, Rebecca Heck Certified Personal Trainer, Susan Eling Certified Personal Trainer, or Jeanette Allen Certified Personal Trainer, in the establishment of a personal physical-fitness program for my benefit, I agree to waive any rights, claims, or damages for injuries which may occur as a result of my participation in said fitness/nutrition program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program.

I understand that Linda Mitchell, Rebecca Heck, Susan Eling, and Jeannette Allen are Certified Personal Trainer and not a medical doctors, and that she will in fact be relying on my representations and disclosures regarding my health and physical condition.

I also do not hold the aforementioned institutions liable for any personal injuries, bodily injuries, or property damage while going to and from the aforementioned property.

The Chickfit Studio LLC Personal Training diet programs are solely intended to assist client with their body re-composition (loss of body fat and/or Increase lean muscle mass.) not treat medical/nutritional concerns. If these concerns exist then physician approval for nutrition guidance is recommended. You must be 18 years of age or older, otherwise written parental permission must be given.

I understand the above and the information provided to me is intended only for my stated body reshaping (re-composition) goals. I further understand that it is my responsibility-decision to obtain medical approval for participation in nutritional program given by Linda Mitchell I agree to assume risk of contracted service indicated and further agree to hold harmless Linda Mitchell and any affiliated staff from any and all claims that may result in morbidity or mortality, accidental, or otherwise, during, or arising in any way from, contracted service.